Air Ontario Flight 1363
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| Summary | |
|---|---|
| Date | 10 March 1989 |
| Type | Crash on takeoff |
| Site | Dryden, Ontario |
| Passengers | 65 |
| Crew | 4 |
| Injuries | 0 |
| Fatalities | 24 |
| Survivors | 45 |
| Aircraft type | Fokker F28-1000 |
| Operator | Air Ontario |
| Tail number | C-FONF |
Air Ontario Flight 1363 was an Air Ontario flight of a Fokker F28-1000 Fellowship which crashed near Dryden, Ontario on March 10, 1989 immediately after take-off en route from Thunder Bay to Winnipeg via Dryden. The aircraft crashed after only 15 seconds because it was not able to achieve enough altitude to clear the trees beyond the end of the runway due to ice and snow on the wings, causing the death of 21 of 65 passengers and 3 of 4 crew members. Some of the survivors were able to escape from the plane on their own but the others were carried to safety.
[edit] Investigation
The investigation revealed that an unserviceable auxiliary power unit (APU), and no available external power unit at Dryden Municipal Airport, led to questionable decision-making which were critical factors leading to the crash of Flight 1363. If the engines had been turned off, they could not be restarted again due to the unservicibility of the APU and lack of external power. Therefore, the engines were left running during the stopover in Dryden. Snow was falling gently that afternoon and although a layer of 0.6 to 1.3 centimetres of snow had accumulated on the wings, the Fokker F-28 aircraft is never supposed to be de-iced while the engines are running. The pilot did not request to have the wings de-iced; at the time airline instructions were unclear on this point but the subsequent report was very critical of this decision.
Fuel needed to be loaded and was done with the engines running while passengers were on board (known as a hot refuel). Off-loading and reloading passengers would have taken considerable time and the longer the aircraft stayed on the ground the greater was the need for the wings to be sprayed with de-icing fluid. The pilot, Captain George C. Morwood, decided to have the aircraft fuelled while the engines were running and with passengers on board. Although this is a very dubious procedure it was not then, and still isn't, prohibited by Transport Canada. Airline instructions were also inconsistent.
[edit] Result
The accident investigation was subsumed into a judicial inquiry under the Honourable Virgil P. Moshansky. His report showed that competitive pressures caused by commercial deregulation cut into safety standards and that many of the industry’s sloppy practices and questionable procedures placed the pilot in a very difficult situation. The report also stated that the aircraft should not have been scheduled to refuel at an airport which did not have proper equipment and that neither training nor manuals had sufficiently warned the pilot of the dangers of ice on the wings. Moshansky blamed Transport Canada for letting Air Ontario expand into operation of bigger, more complicated aircraft without detecting the deficiencies of their existing aircraft.
As a result of the crash of Air Ontario Flight 1363, and the resulting investigation, many significant changes were made to the Canadian Air Safety regulations. These included not only new procedures regarding re-fuelling and de-icing but also many new regulations intended to improve the general safety of all future flights in Canada.
